ABC | Volume 111, Nº5, November 2018

Original Article Sokmen te al Cardiac functions in adrenal incidentaloma Arq Bras Cardiol. 2018; 111(5):656-663 the onset of electrical activity and the mechanical activation of atrial myocardium. Tissue Doppler echocardiography (TDE) is a simple, noninvasive and reliable method to measure atrial EMD. 7 Several studies report that atrial EMD measured by TDE is a valuable parameter to predict new onset AF or recurrence of AF. 8-11 There are few studies evaluating cardiac functions in patients having nonfunctioning AI, but to our knowledge data concerning atrial electromechanical properties are lacking. 5,12 The aim of this study was to assess intra- and inter-atrial conduction times along with cardiac structural and functional characteristics in patients with nonfunctioning AI. Methods Study population All subjects who were referred to the Department of Endocrinology and Metabolism of Kahramanmaras Sutcu Imam University, in Kahramanmaras, Turkey, with incidentally discovered adrenal tumors between March 2014 and November 2015 were recorded (n = 82). The study was approved by local Research Ethics Committee of the institution in compliance with the Declaration of Helsinki. All of the participants gave written consent. At the first visit, all subjects underwent a CT or magnetic resonance imaging (MRI) scan to confirm the diagnosis. Adrenal adenomawas diagnosed if the following criteriaweremet: • tumor size less than 4.0 cm; • regular shape with well-defined margins; • homogenous and attenuation value of 10 or less Hounsfield units on unenhanced CT scan, and 30 or less Hounsfield units on enhanced CT scan. 13 After confirming the presence of adrenal adenoma, detailed physical examination and basal hormonal and dynamic tests were performed. Among participants, 30 patients having nonfunctional adrenal adenomas were included in the study. Totally 52 patients with uncompleted tests or hormone- secreting tumors – high levels of dehydroepiandrosterone sulphate (DHEAS), hyperaldosteronism, Cushing syndrome (CS), pheochromocytoma – and patients having large adrenal tumors (>4 cm) with irregular borders and invasion to adjacent structures raising the suspicion of malignancy were excluded. Additionally, patients with known malignancies, coronary artery disease, valvular heart diseases, cardiomyopathies, thyroid dysfunction, chronic renal failure, liver failure, previous surrenal or hypophysial intervention or patients taking steroids were not included in the study. In an attempt to determine the hormonal activity of adrenal tumors, blood samples were collected at 8.30 am to analyze sodium (Na), potassium (K), adrenocorticotropic hormone (ACTH), DHEAS and plasma cortisol levels. For exclusion of CS, 1 mg dexamethasone suppression test (DST), the most common screening test for CS, was performed to the patients. The suppression in overnight DST was adequate when morning cortisol level fell below 1.8 µ/dl. Blood samples for plasma renin and aldosterone measurements were collected after at least 4–6 hours of nocturnal resting, following two hours of standing or wandering, and after 15 minutes of resting, respectively. Plasma aldosterone concentration (PAC)/plasma renin activity (PRA) ratio was used as the screening test to exclude primary aldosteronism. PAC/PRA ≤ 20 values were accepted as normal. 14 Moreover, patients were given a diet free of food containing phenolic acid for five days. Then, 24‑hour urine specimens were collected for metanephrine and normetanephrine analyses. Pheochromocytoma was defined as elevated levels of urinary normetanephrine (normal range: 88–444 µg/day) and/or urinary metanephrine (normal range: 52–341 µg/day). 13 Age and sex matched 46 subjects without clinical suspicion of hypercortisolism, with normal DHEAS level (female 35–430 µg/dl, male 80–560 µg/dl), suppressed 1 mg DST (≤ 1.8 µg/dl) and without adrenal mass on abdominal ultrasonography were taken as the control group. Blood pressure measurements of all subjects were taken from right arm in the sitting position after 5 minutes of resting. Height (meter) and weights (kg) of all participants were recorded, and body mass index (BMI, kg/m 2 ) was calculated. Conventional echocardiographic examination All participants were performed transthoracic echocardiography (Vivid 7 Pro, GE, Horten, Norway, 2–4 MHz phased array transducer), including two-dimensional, M-mode, pulsed, and color flow Doppler examinations by the same experienced cardiologist blinded to the clinical status of the subjects. Recordings weremade on left lateral decubitus position by using standard parasternal, apical, and subcostal views. Left atrial dimension, left ventricular (LV) end-diastolic and end‑systolic diameters, diastolic thickness of ventricular septum and posterior wall were measured from M-mode in parasternal long axis view according to the criteria of the American Society of Echocardiography guidelines. The early (E-wave) and late diastolic (A-wave) velocities of mitral inflow were measured from apical four chamber view with pulsed Doppler echocardiography by placing the sample volume at the tips of mitral leaflets, and E/A ratiowas calculated. Ejection fractionwas estimated by Simpson’s rule. LV mass was calculated by Devereux formula and indexed to the body surface area. 15-17 Right ventricular (RV) morphological and functional parameters including right atrial dimension, RV diameter, and tricuspid annular plane systolic excursion (TAPSE) were measured according to the American Society of Echocardiography guidelines. 15 Systolic pulmonary artery pressure (sPAP) was obtained from the maximum velocity of the regurgitant tricuspid jet, and pulmonary acceleration time (PAT) was measured as the time between the onset and peak of pulmonary velocity obtained by pulsed Doppler recording. 18 Tissue doppler echocardiography and atrial electromechanical delay TDE was performed with transducer frequencies of 3.5–4.0 MHz using a 5 mm pulsed Doppler sample volume. Spectral Doppler signal filters were set to obtain a Nyquist limit of 15 to 20 cm/s with minimal optimal gain settings. The sweep speed was set at 50 to 100 mm/s. A single lead electrocardiogram (ECG) was recorded simultaneously during measurements. In the apical four chamber view, the sample 657